Cost-Effectiveness of Immediate Lymphatic Reconstruction Versus Structured Surveillance for Preventing Breast Cancer–Related Lymphedema After Axillary Surgery

Background Breast cancer–related lymphedema (BCRL) is a common and costly complication after axillary lymph-node dissection (ALND). Immediate lymphatic reconstruction (ILR) has been introduced as a preventive surgical strategy, but its economic value relative to structured postoperative surveillance in health systems with established lymphedema services remains uncertain. Methods We conducted a decision-analytic cost-effectiveness analysis comparing three strategies after ALND: opportunistic detection, structured surveillance using bioimpedance spectroscopy and indocyanine green lymphography, and ILR. The model adopted a societal perspective over a 10-year horizon with 3% annual discounting. Clinical probabilities were derived from meta-analyses and local cohort data, while costs were obtained from national tariff benchmarks and institutional billing data. Outcomes were expressed as quality-adjusted life-years (QALYs). Parameter uncertainty was explored using probabilistic and one-way sensitivity analyses, and threshold analyses examined conditions under which ILR might become cost-effective. Results Structured surveillance dominated opportunistic detection, yielding higher QALYs at lower cost. ILR provided a modest additional health benefit but at substantially higher cost, resulting in an incremental cost-effectiveness ratio well above commonly accepted willingness-to-pay thresholds. In probabilistic analyses, structured surveillance was cost-effective in more than 95% of simulations, whereas ILR was not cost-effective in any iteration at conventional thresholds. Threshold analyses indicated that ILR would require substantially lower surgical costs or markedly higher baseline BCRL incidence to become economically viable. Conclusions In a health system with access to structured lymphedema surveillance and early conservative management, routine ILR is unlikely to represent an efficient use of healthcare resources. These findings support prioritising structured surveillance pathways and reserving ILR for selected high-risk or preference-sensitive cases.